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COOPERATION BETWEEN DOCTOR AND NURSE
1420 MANAGEMENT AND ADVICE AT THE GRASS ROOTS
SIR,-Mr Kirk and Professor Bennett (May 24, p. 1180) draw attention to the " gap between clinical practice and district management". This gap has been successfully closed in their community hospitals by a team consisting of a general practitioner, a senior nursing officer, and a local health service administrator. In the district general hospital a similar mechanism is needed and could perhaps be provided by an extension of the " information rooms " in service at Southampton. These rooms are situated beside the wards of a clinical specialty, undertake the management tasks for about one hundred beds, and organise the practices of four or five consultants. Secretarial and clerical services could be brought together in these rooms and daily control exercised by a meeting of the senior registrar, the nursing officer, and a higher clerical officer. This could be the first point in the information system with monthly reports going to the Cogwheel division and abstracts to the district medical committee and team. Conversely these committees would delegate short-term authority to the " information team " to interpret and act on the former’s instructions. The team and room would thereby become the daily executive arm, and make it possible to reconcile the contradictory needs of individualism in the medical and social care of the patient, and standardisation for administrative and financial gain. This of course goes against the present trend which is to centralise all administrative functions, with specified officers carrying out particular tasks for every clinical team. This centralisation has obvious administrative appeal but the individual officers cannot be expected to have insight into the total functioning of forty separate clinical teams. The secretaries will type the summaries and the clinic letters but know nothing of the admissions or of present problems in the wards. The admission officer knows little of the operating-list or of the ward policies. The ward sisters know the inpatients and the lists, but not the outpatients. This leaves the medical staff as the only general link and they might all be in theatre. This limitation of understanding militates strongly against the single hospital centre acting as the focal point for the daily reconciliation of possibly contradictory claims of medical effectiveness and administrative efficiency. The information rooms take more space and cost more money, but the investment makes a-priori sense in terms of a million-pound district specialty budget, as for instance in surgery, and the care of 5000 patients a year. At the very least a trial of the merits of the two systems would seem justified. Department of Community Medicine, St. Thomas’s Hospital Medical School, London SE1 7EH.
PETER SIMPSON.
COOPERATION BETWEEN DOCTOR AND NURSE
SIR,-We write from practical experience to support your leading article (April 12, p. 842) on the advantages of the provision of health care jointly by doctor and nurse. The main functions of the primary-care nurse as applied to a busy London N.H.S. general practice are, in our
opinion: (1) Standard nursing
duties (temperatures, most injections, testing, dressings, &c.). (2) Taking full routine medical history of new patients. (3) Taking history of presenting illness of children and infants. (4) Developmental screening of infants and pre-school
urine
children.
(5) Taking blood-pressure readings as a routine screening follow-up of hypertensive patients. of Assessment severity of overweight and supervision of (6)
examination and for
weight reduction. (7) Carrying out special investigations: venous blood sampling, electrocardiography, peak-flow-rate measurements, allergy testing, and urine dip-slide culturing of mid-stream specimens. (8) Ear syringing. (9) Home visiting (e.g., for house-bound patients, and to supervise dust-avoidance measures in cases of house-dust-mite allergy). The cooperation of doctor and nurse facilitates routine basic screening, health education, and first-line investigations, as well as attending to the patient’s immediate needs. 18 Anson
JEFFREY SEGALL
Road,
ELAINE LEE.
London NW2 3UU.
WHAT FUTURE FOR PERINATAL CARE?
SIR,—Your editorial is timely although half of
that
deaths
your estimate
nearly perinatal preventable by knowledge is optimistic. Superspecialism in neonatology is not new but inadequately developed and represented in the United Kingdom. In obstetrics, perinatal death and long-term morbidity are not yet clearly recognised as requiring full-time or nearly full-time clinical research effort. It is significant that in the United States, where perinatal medicine with endocrinology and oncology have specialty boards, it is in perinatal medicine that there is a real shortage of experts or of young doctors in training. Oncology and endocrinology are more defined and more recently popular. As you suggest, we must in obstetrics and paediatrics follow our American friends at least a good are
current
bit of the way. Department of Obstetrics and Gynæcology, Ninewells Hospital, Dundee DD1 9SY.
JAMES WALKER.
THE MELANCHOLY OF ANATOMY
SIR,-I have long been convinced that, if you scratch any member of the medical profession, you will discover a would-be expert on the teaching of anatomy, carrying a large blunt axe which he is anxious to grind. The letter from Dr Bull (June 7, p. 1290) provides further evidence for this notion. He is understandably pleased about the progress which has been made in the techniques of radiology, citing the fact that neuroradiologists have doubled the number of recognisable cerebral vessels. The relevance of this to the teaching of anatomy to undergraduates is not clear, unless Dr Bull is advocating that they should be taught more, rather than less, detail. He complains that anatomists are blind to radiology; in this department, which is not untypical, radiologists regularly lecture on the radiological aspects of the region which the students are dissecting, and appropriate radiographs are displayed in the dissecting-room and are discussed in tutorials. Anatomists do use radiology in their teaching and in their research when it is appropriate to do so. Dr Bull complains that anatomists are not trained to use radiology. It would be equally pointless for an anatomist to complain that radiologists are not trained to use electron microscopy, histochemistry, tissue culture, or autoradiography. I recall a discussion in the Board of Medicine here some years ago when the (then) professor of radiodiagnosis was urging us to teach gross anatomy by means of radiographs. The discussion was terminated when a member of the board
SIR,-Mr Kirk and Professor Bennett (May 24, p. 1180) draw attention to the " gap between clinical practice and district management". This gap has been successfully closed in their community hospitals by a team consisting of a general practitioner, a senior nursing officer, and a local health service administrator. In the district general hospital a similar mechanism is needed and could perhaps be provided by an extension of the " information rooms " in service at Southampton. These rooms are situated beside the wards of a clinical specialty, undertake the management tasks for about one hundred beds, and organise the practices of four or five consultants. Secretarial and clerical services could be brought together in these rooms and daily control exercised by a meeting of the senior registrar, the nursing officer, and a higher clerical officer. This could be the first point in the information system with monthly reports going to the Cogwheel division and abstracts to the district medical committee and team. Conversely these committees would delegate short-term authority to the " information team " to interpret and act on the former’s instructions. The team and room would thereby become the daily executive arm, and make it possible to reconcile the contradictory needs of individualism in the medical and social care of the patient, and standardisation for administrative and financial gain. This of course goes against the present trend which is to centralise all administrative functions, with specified officers carrying out particular tasks for every clinical team. This centralisation has obvious administrative appeal but the individual officers cannot be expected to have insight into the total functioning of forty separate clinical teams. The secretaries will type the summaries and the clinic letters but know nothing of the admissions or of present problems in the wards. The admission officer knows little of the operating-list or of the ward policies. The ward sisters know the inpatients and the lists, but not the outpatients. This leaves the medical staff as the only general link and they might all be in theatre. This limitation of understanding militates strongly against the single hospital centre acting as the focal point for the daily reconciliation of possibly contradictory claims of medical effectiveness and administrative efficiency. The information rooms take more space and cost more money, but the investment makes a-priori sense in terms of a million-pound district specialty budget, as for instance in surgery, and the care of 5000 patients a year. At the very least a trial of the merits of the two systems would seem justified. Department of Community Medicine, St. Thomas’s Hospital Medical School, London SE1 7EH.
PETER SIMPSON.
COOPERATION BETWEEN DOCTOR AND NURSE
SIR,-We write from practical experience to support your leading article (April 12, p. 842) on the advantages of the provision of health care jointly by doctor and nurse. The main functions of the primary-care nurse as applied to a busy London N.H.S. general practice are, in our
opinion: (1) Standard nursing
duties (temperatures, most injections, testing, dressings, &c.). (2) Taking full routine medical history of new patients. (3) Taking history of presenting illness of children and infants. (4) Developmental screening of infants and pre-school
urine
children.
(5) Taking blood-pressure readings as a routine screening follow-up of hypertensive patients. of Assessment severity of overweight and supervision of (6)
examination and for
weight reduction. (7) Carrying out special investigations: venous blood sampling, electrocardiography, peak-flow-rate measurements, allergy testing, and urine dip-slide culturing of mid-stream specimens. (8) Ear syringing. (9) Home visiting (e.g., for house-bound patients, and to supervise dust-avoidance measures in cases of house-dust-mite allergy). The cooperation of doctor and nurse facilitates routine basic screening, health education, and first-line investigations, as well as attending to the patient’s immediate needs. 18 Anson
JEFFREY SEGALL
Road,
ELAINE LEE.
London NW2 3UU.
WHAT FUTURE FOR PERINATAL CARE?
SIR,—Your editorial is timely although half of
that
deaths
your estimate
nearly perinatal preventable by knowledge is optimistic. Superspecialism in neonatology is not new but inadequately developed and represented in the United Kingdom. In obstetrics, perinatal death and long-term morbidity are not yet clearly recognised as requiring full-time or nearly full-time clinical research effort. It is significant that in the United States, where perinatal medicine with endocrinology and oncology have specialty boards, it is in perinatal medicine that there is a real shortage of experts or of young doctors in training. Oncology and endocrinology are more defined and more recently popular. As you suggest, we must in obstetrics and paediatrics follow our American friends at least a good are
current
bit of the way. Department of Obstetrics and Gynæcology, Ninewells Hospital, Dundee DD1 9SY.
JAMES WALKER.
THE MELANCHOLY OF ANATOMY
SIR,-I have long been convinced that, if you scratch any member of the medical profession, you will discover a would-be expert on the teaching of anatomy, carrying a large blunt axe which he is anxious to grind. The letter from Dr Bull (June 7, p. 1290) provides further evidence for this notion. He is understandably pleased about the progress which has been made in the techniques of radiology, citing the fact that neuroradiologists have doubled the number of recognisable cerebral vessels. The relevance of this to the teaching of anatomy to undergraduates is not clear, unless Dr Bull is advocating that they should be taught more, rather than less, detail. He complains that anatomists are blind to radiology; in this department, which is not untypical, radiologists regularly lecture on the radiological aspects of the region which the students are dissecting, and appropriate radiographs are displayed in the dissecting-room and are discussed in tutorials. Anatomists do use radiology in their teaching and in their research when it is appropriate to do so. Dr Bull complains that anatomists are not trained to use radiology. It would be equally pointless for an anatomist to complain that radiologists are not trained to use electron microscopy, histochemistry, tissue culture, or autoradiography. I recall a discussion in the Board of Medicine here some years ago when the (then) professor of radiodiagnosis was urging us to teach gross anatomy by means of radiographs. The discussion was terminated when a member of the board